The first line treatment for PMS and PMDD is selective serotonin reuptake inhibitors (SSRIs), which have been proven to be successful in reducing mood symptoms. This is because of the condition’s resemblance to depression. ‘As evidenced by SSRIs administration being effective, developing PMS/PMDD might be promoted by mental stress and the deficiency of serotonin is considered to be a pathological background,’ explains Kawamura. ‘Such pathological hypothesis would be shared with that of major depressive disorder (MDD). PMS/PMDD also bears a strong resemblance to MDD in terms of symptoms and therapeutic drugs.’ However, in Japan, there is an issue surrounding the acceptance of psychotropic drugs, which means that women may not feel comfortable or indeed able to take them. Therefore, Kawamura and her team are exploring an alternative method of treatment. The researchers are focusing on the emotional expression (EE) of patients’ families, and family psycho-education and seeking to verify the impact of these approaches on PMS/PMDD. Due to the shared similarities of MDD and PMS/PMDD, they hypothesised that they could, on the basis of accumulating evidence for non-pharmacotherapeutic approaches to treating MDD, adapt such approaches and apply them to PMS/PMDD. ‘In recent years, the efficacy of non-pharmacological therapy as a remission maintenance therapy after acute phase drug treatment for psychiatric diseases prone to relapse has been studied, and not only cognitive behavioural therapy for the patient but also the effectiveness of family psycho-education which intervene in behavioural feature of patient families has been reported,’ Kawamura outlines. For example, research has shown that when it comes to psychological illnesses that have a high relapse rate, similar to that of PMS/PMDD, there is a correlation between a family member’s critical, over-possessive or over-protective EE and relapse rates. ‘There is growing evidence in these diseases that family psycho-education reduces the relapse rate of patients by intervening such behavioural features of the family members,’ she says. The researchers believe that in patients with PMS and PMDD, impairment in emotional control before menstruation can worsen a patient’s relationship with their family members, which can, in turn, lead to a worsening of PMS/PMDD symptoms due to stress caused by family interactions. This is why they believe that family psycho-education programmes could be effective. ‘Such a vicious cycle explaining the symptom exacerbation/prolonging factor is similar to that of patients with MDD or bipolar disorder and their families,’ highlights Kawamura. ‘Therefore, also in PMS/PMDD, family member’s critical, over-possessive or overprotective EE is strongly suspected as a factor to amplify this vicious cycle. Family psycho-education for PMS/PMDD would be expected to eliminate such vicious cycle and be effective in promoting relapse-preventive family communication’. She points out that in their research, they aim to develop an ‘efficacious family psycho-education programme’ which has a purpose of preventing the relapse of PMS/PMDD after verifying the association between patients’ families’ EE and relapse.